Chapter 19: Alcohol Use in Adolescence 217 Chapter 19 Alcohol use in adolescence David Fergusson Christchurch Health and Development Study, University of Otago, Christchurch Joseph Boden Christchurch Health and Development Study, University of Otago, Christchurch Summary • There is consistent evidence to suggest that a substanal fracon of New Zealand young people engage in heavy drinking including hazardous drinking, alcohol abuse and alcohol dependence. Over a third of young people engage in binge drinking or hazardous drinking and by the age of 25 over 20% will have developed a significant alcohol related problem. • The misuse of alcohol by young people has been associated with increased risks of a number of adverse outcomes including: motor vehicle collisions, injuries and deaths; crime; violence; sexual risk taking; mental health problems and vicmisaon. • There is increasing internaonal evidence on the types of policies that are effecve in reducing the risks of alcohol related problems in young people. Effecve policies include: increased alcohol taxaon; regulang the availability of alcohol; regulaon of drink driving; alcohol markeng restricons; development of effecve treatment services. • Approaches having lile or no effecveness include: alcohol and drug educaon in schools; public service adversements advocang responsible drinking and avoidance of drink driving; warning labels on alcohol containers. • The recent Law Commission report provides a comprehensive and evidence-based framework for reforming the supply and regulaon of alcohol in New Zealand. • Key reforms that are likely to benefit young people include: increasing the cost of alcohol; raising the drinking age and the age at which alcohol may be purchased to 21 years; adopng a zero tolerance policy for drink driving by under 21 year olds; further restricon on the adversing of alcohol; greater regulaon of hours of sale, number of outlets and supply of alcohol in licensed premises frequented by young people; greater investment in treatment for young people with significant alcohol related problems. • Greater investment is required in evaluaon research to ascertain the extent to which policy changes have beneficial effects in reducing the misuse of alcohol by young people.
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Chapter 19: Alcohol Use in Adolescence
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Chapter 19
Alcohol use in adolescence
David FergussonChristchurch Health and Development Study, University of Otago, Christchurch
Joseph BodenChristchurch Health and Development Study, University of Otago, Christchurch
Summary• There is consistent evidence to suggest that a substantial fraction of New Zealand
young people engage in heavy drinking including hazardous drinking, alcohol abuse andalcoholdependence.Overa thirdof youngpeopleengage inbingedrinkingorhazardousdrinkingandbytheageof25over20%willhavedevelopedasignificantalcohol related problem.
• There is increasing internationalevidenceonthetypesofpolicies thatareeffectivein reducing the risksofalcohol relatedproblems inyoungpeople.Effectivepoliciesinclude: increased alcohol taxation; regulating the availability of alcohol; regulationof drinkdriving; alcoholmarketing restrictions; developmentof effective treatmentservices.
• Approaches having little or no effectiveness include: alcohol and drug education inschools;publicserviceadvertisementsadvocatingresponsibledrinkingandavoidanceofdrinkdriving;warninglabelsonalcoholcontainers.
• The recent Law Commission report provides a comprehensive and evidence-basedframeworkforreformingthesupplyandregulationofalcoholinNewZealand.
• Key reforms that are likely to benefit young people include: increasing the cost ofalcohol;raisingthedrinkingageandtheageatwhichalcoholmaybepurchasedto21years;adoptingazerotolerancepolicyfordrinkdrivingbyunder21yearolds;furtherrestrictionontheadvertisingofalcohol;greaterregulationofhoursofsale,numberofoutletsandsupplyofalcoholinlicensedpremisesfrequentedbyyoungpeople;greaterinvestmentintreatmentforyoungpeoplewithsignificantalcoholrelatedproblems.
• Greaterinvestmentisrequiredinevaluationresearchtoascertaintheextenttowhichpolicy changes have beneficial effects in reducing the misuse of alcohol by youngpeople.
2. What is the question?AlcoholiswidelyusedandmisusedbyyoungNewZealanderswithestimatessuggestingthat over 1 in 3 young people aged 12-16 engage in binge drinking [1]with a similarfractionofyoungpeopleaged16-21engaginginhazardousdrinking[2].Therehavebeenongoing public concerns expressed about young people and alcohol in both the NewZealandmediaandinofficialreports.Thegrowingstatisticalevidenceandpublicconcernsraisethreeimportantquestionsaboutalcoholandyoungpeople.
• Thethirdquestionconcernsthedevelopmentofprevention,treatmentandrelatedservices aimed at both reducing heavy drinking by young people and providing treatmentforyoungpeoplewithalcoholrelatedproblems.
3. Why is alcohol use important in the transition to adolescence?There isgrowingand internationallyconsistentevidencetosuggest thattheheavyuseofalcoholbyyoungpeoplemakessubstantialcontributionstorisksofarangeofadverseconditionsinadolescence.Amongsttheadverseeffectsthathavebeendocumentedarethefollowing.
3.1 Increased risks of motor vehicle collisions, injuries and deathsThetransitiontoadolescence includestworitesofpassagethathaveconsequencesofincreasingtherisksofinjuryandmortalityfrommotorvehicles.First,overtheperiodofadolescencethemajorityofyoungpeoplebegintousealcoholaspartofsocialactivities.Forexample,estimatesfromtheChristchurchHealthandDevelopmentstudysuggestthatbytheageof15over70%ofyoungpeoplereporteddrinkingwithinthelastyearwith30%reportingdrinkingatleastoncepermonth[3].Second,theonsetofdrinkingbehaviourscoincideswithageatwhichadrivinglicencecanbeobtainedwith15beingtheageforacquiringalearner’slicence.Thecombinationofthesetwoeventsplacesadolescentsatriskofdrinkdrivingwiththeattendantharmsofmotorvehiclecollisions,injuryanddeath[4-7].
3.2 Increased risks of crimeThereisnowsubstantialevidencetosuggestthatthedisinhibitingeffectsofalcoholplaceteenagersat increasedrisksofa rangeofcrimes including:violence;vandalism;sexualcrimes; partner violence andproperty crimes [8-29]. This scientific evidence has beensupplementedbygrowingamountsofvideomaterialofpublicareasthathasdocumentedthewaysinwhichthemisuseofalcoholfuelsantisocialbehavioursbyyoungpeople[30].
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3.3 Increased risks of sexual risk takingThe heavy use of alcohol is also associated with increased risks of sexual risk takingincludingmultiplesexualpartnershipsandunprotectedsex[31-33].Inturnthisincreasedrate of sexual risk taking is associatedwith increases in sexually transmitted diseases,pregnancyandabortion[32-35].
3.4 Mental health problems and suicidal behavioursThere is increasingevidence to implicate themisuseof alcohol in thedevelopmentofmentaldisorderssuchasdepression[3,36-44]andthedevelopmentofsuicidalbehavioursinyoungpeople[13,45-47].
3.5 VictimisationThe social context within which alcohol is consumed means that not only are youngdrinkersatriskofbehavinginatriskways,theyarealsoatincreasedriskofbecomingthevictimsofdrinkdrivingandalcoholfuelledcrimes[19,29,48-52].
“One of the greatest challenges we face around alcohol is how to reconcile the new evidence of the risks alcohol presents to young people with our cultural norms. Drinking to intoxication is commonly seen in our society as a rite of passage and drinking to intoxication is not only socially accepted but expected. New research has shown that young people experience more harm per standard drink than older drinkers. The highest risk is for those under 15 years but there is still an elevated risk of harm per drink for young people up to the age of 25 years.”(p.83)[53]
Inaddition,theLawCommissionnotes:
“It is hard to think of any other lawful product available in our society that contributes to so many social ills. While alcohol misuse is only one of several risk factors contributing to these harms, alcohol distinguishes itself because, like many other factors associated with crime, injury and social dysfunction, the harmful use of alcohol is a modifiable risk factor.” (p.7)[54]
4. What is the scale of the problem?AnumberofNewZealandpublicationshave sought to estimate the fractionof youngpeoplewhoareat riskbecauseof theheavyconsumptionofalcohol [1,2,18,53-59].However,differentstudieshaveusedsomedifferentapproaches. Instudiesofyoungerteenagers, ratesofbingedrinkinghavebeenused toassess thesizeofalcohol relatedproblems. Forexample theYouth2007 survey reports34%of youngpeopleage12 to17 engaged in binge drinking in the lastmonth where binge drinking was defined asdrinkingmorethan5alcoholicdrinksinfourhours[1].TheNewZealandMentalHealthSurvey(TeRauHinengaro)reportedarangeofmeasuresappliedto16to24yearolds[2,55].Thesemeasuresincludeassessmentofthenumberofyoungpeopleengaginginhazardousdrinkingaswellasthosemeetingformaldiagnosticcriteriaforalcoholabuseanddependence.TeRauHinengarofoundthat79%ofyoungpeopleaged16-24drankintheprevious12monthsand49%ofthosedrinkersdrankhazardouslyinthatperiod.Thesamestudyshowedthat,regardlessofdrinkingstatus,nearly17%hadevermetDSMIVcriteria foralcoholabusewith6.5%havingmetcriteria foralcoholdependence.These
Allofthesefiguresareindicativeofalargeandgrowingproblemwiththemisuseofalcoholby youngpeople [53, 54].Given the consequences of themisuse of alcohol by youngpeopleforawiderangeofoutcomes,findingconstructivewaysofmeansofregulatingtheuseofalcoholbyyoungpeopleandmitigatingtheadverseeffectsofalcoholmisuseisamatterofhighpriorityintheareaofadolescentpolicy.
5. What does research tell us about causative factors?Therehasbeenextensiveresearchintothefactorsassociatedwiththeuseandmisuseofalcoholbyyoungpeople.Thesefactorsincludethefollowing.
5.1 Genetic factorsThere has been growing evidence from both twin studies and behavioural geneticresearchtosuggestgeneticfactorsmayplayanimportantroleindeterminingindividualsusceptibilitytoalcoholabuseanddependence[60-65].Estimatessuggestthatupto60%ofthevariationinalcoholabuseanddependencemaybeaccountedforbygeneticfactors[66].Itislikelythatgeneticfactorsinteractwithenvironmentalinfluencessothatthosemostatriskofalcoholrelatedproblemsarebothgeneticallysusceptibletotheseproblemsandareexposedtosocialenvironmentsthatencouragethemisuseofalcohol[67].
5.2 Socio-demographic factorsThere is extensive evidence which suggests higher rates of alcohol misuse amongstcertain groups within the population. Males are more likely to misuse alcohol thanfemalesalthoughrecentevidencesuggeststhatthegendergapinthisarea isreducingamongst young people [68-72]. Youngpeople from socially disadvantagedbackgroundcharacterisedbylowfamilyincomeandsocio-economicstatusareatgreaterrisk[73,74].InNewZealandyoungMāorihaveratesofalcoholabuseanddependencethatarehigherthanthoseofnonMāori[53,54,75,76].
5.3 Family factorsAlargeamountofresearchsuggeststhatthenatureandqualityofthefamilyenvironmentplaysan importantrole inpredisposingyoungpeopletothemisuseofalcohol.Factorsassociatedwithalcoholmisusebyyoungpeopleinclude:parentalalcoholproblems;earlyageoffirstdrink;familydysfunction,childhoodmaltreatmentandrelatedconditions[21,77-85].
5.4 Peer influencesAmongst adolescents peer affiliations play an important role in the development ofsubstanceuseandabuse,withyoungpeoplewhoaffiliatewithsubstanceusingfriendsandacquaintancesbeingatincreasedrisksoftheuseandmisuseofalcohol[85-89].
5.5 Access to alcoholThere is extensive evidence to suggest that factors that influence the availability and
Themajor conclusions that emerge from research into the causative factors involvedinthedevelopmentofalcoholuseandmisuseare likelyto involveacomplex interplayofbiological, social, familial,peerandother factorswhichcombine todetermineratesofalcoholuseandmisuse intheadolescentpopulation.Considerationof thesefactorssuggeststhatapproacheswhichfocusonregulatingtheaccessofyoungpeopletoalcoholofferthegreatestpotentialforminimisingalcoholmisuseinthispopulation.
6. Prevention, treatment and management of alcohol use/misuse in adolescence
There is a large and extensive literature on the effective policies for the regulation ofalcohol and the prevention, treatment andmanagement of alcohol related problems.Thismaterialhasbeenablysummarisedintheaward-winningtextAlcohol – No Ordinary Commodity [91]. Chapter 16 of that text provides an overview and summary of theeffectivenessof42strategiesandpoliciesthathavebeenusedaroundtheworldfortheregulation,preventionandtreatmentofalcoholmisuse.Keyconclusionsofthisreviewaresummarisedbelow.
6.1 Increased alcohol taxationThereisconsistentevidencefromaroundtheworldthatincreasingthetaxationofalcohol(andthencethepriceofalcohol)isoneofthemosteffectivemethodsforreducingalcoholconsumptionandrelatedharms.Thisapproachhasbeenfoundtobemoreeffectiveinreducing heavy drinking and is likely to be effective in reducing alcohol consumptionamongstyoungerdrinkers[92-95].
6.2 Regulating the availability of alcoholThereisalsostrongevidencethatregulatingtheavailabilityofalcoholalsohasbenefitsin reducing alcohol consumption and harm. The evidence suggests that by restrictingthehoursofsale,thetimesofthedaywhenalcoholissoldandthelocationofalcoholsalepremisesandsimilarfactorsitispossibletoreducelevelsofconsumptionandratesofalcoholrelatedproblems[96-99].Aformofalcoholregulationthat isusedwidely isregulationofthelegalageatwhichalcoholcanbepurchased.ThereisgoodevidencefromUS-basedresearchthatraisingtheminimumdrinkingageto21andadequatelyenforcingthelawleadstoreductionsinalcoholrelatedharmsamongstyoungpeople[100-104].
6.3 The regulation of drink drivingAfurthermovethathasbeenshowntobeeffective in reducingalcohol relatedharmsisrestrictionsondrinkdrivingincludingloweringthelegalbreathalcoholconcentrationand ensuring that drink driving laws are visibly enforced by the use of check points,randombreathtestsandstrongpenalties[105-108].Withrespecttoadolescentsithasbeenproposedthatzerotolerancepoliciesregardingbreathalcoholconcentrationsare
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effective in reducing ratesofdrinkdrivingamongst thosebelowthe legaldrinkingage[109-112].
6.5 Altering the drinking contextAfurtherstrategythathasbeenfoundtohavemodesteffectsinreducingrisksofalcoholconsumptionandharmisgreaterregulationandoversightofdrinkingestablishmentsandalcoholsupplyoutletstoensurethatregulationsregardingalcoholconsumptionrelatingtoageofsupplyandlevelsofintoxicationareadequatelyenforced[115-117].
6.6 Development of effective treatment servicesThe preceding approaches have all relied on changing the policy environment in various ways to reduce levelsofhazardousdrinkingandalcohol relatedharms.However,evenwiththemosteffectivepopulationlevelpoliciesanumberofyoungpeoplewilldevelopsignificantalcoholrelatedproblemsandrequiretreatmentandsupport.
Therehasbeenagrowingresearchliteratureonthedevelopmentofinterventionsaimedattreatingandassistingpeoplewithalcoholrelatedproblems.Thisresearchhasidentifiedanumberoftreatmentapproachesasbeingeffective.Theseinclude:briefinterventionsaimedatreducingtherisksfacedbyhazardousandhighriskdrinkers;cognitivebehavioural,motivationalenhancementandrelatedtherapies;andmutualaidtreatments[118-120].Paralleltothedevelopmentoftheseinterventionstherehasbeenagrowingnumberofbest practice guidelines for the development of treatment for adolescent populationswithalcoholrelatedproblems[46,121-123].
7. What does not workWhilethereisgrowingevidenceoneffectivestrategiesforreducingalcoholrelatedharm,thereisalsoagrowingconsensusabouttheapproacheswhicharelikelytobeineffective.Theseapproachesincludethefollowing.
7.1 Alcohol and drug education in schoolsAround the world there have been investments made in alcohol and drug educationprogrammesthatseektoteachyoungpeopleabouttherisksofalcoholanddrugsandreducetherisksoffutureuseandabuseofsubstances.Thereisnowgenerallyconsistentevidence to suggest that while alcohol and drug education increases young people’sknowledgeaboutthesesubstances, itdoesnotgenerallyreducetherisksoffutureuseandabuseofsubstances[124-127].
Therehave,however,beensomeexceptionstothesefindings.Inparticular,therehasbeenpromisingevidencethatthe“Keepin’ itREAL”programmemaybeeffectiveinreducingdrug and alcohol abuse in young people [128-133]. Keepin’ it REAL is amulticultural,school-based substance use prevention program for students 12-14 years old. Keepin’itREALusesa10-lessoncurriculumtaughtbytrainedclassroomteachers in45-minute
7.2 Mass media campaignsParalleltoalcoholanddrugeducation,therehavebeenlargeinvestmentsmadeinmediacampaigns aimed at encouraging responsible drinking and highlighting the hazards ofbehaviourssuchasdrinkdriving.Despitetheinvestmentmadeintosuchcampaignstheevidencefortheireffectivenessinreducingalcoholconsumptionoralcoholrelatedharmsis very limited.Manyprogrammeshavenot shown theexpectedgainsandchanges inbehaviours[134,135].IncommentingonthisareaBaboretal[91]note:
“Despite their good intentions, Public Service Advertisements are not an effective antidote to the high quality pro drinking messages that appear much more frequently as paid advertisements in the mass media.” (p.202)
7.3 Warning labelsAthirdapproachthathasbeenusedhasbeentorequirethatalcoholbeveragecontainerscarry labels warning consumers of the risks of excessive alcohol use. Reviews of theevidence suggest that such labels have nomeasureable beneficial effects on levels ofalcoholconsumptionoralcoholrelatedharm[136-138].
Acommonthemethatappearstouniteinterventionsthatdonotworkisthatallinvolvemethodsofeducationandrationalpersuasionthatseektodiscouragetheexcessiveuseofalcohol.Regrettablytheweightoftheevidencesuggeststhatreasonableandrationalappeals are not effective in reducing rates of alcohol consumption or alcohol relatedharms.
8. Where are policy/intervention currently focused?Recently there have been growing public concerns stated about the issue of problemdrinkinginNewZealandwithmanyoftheseconcernsfocusingontheissueofhazardousdrinking by young people. These concerns have been reinforced by highly publicisedeventsinwhichyoungpeoplehavediedasaresultoftheexcessiveuseofalcoholbothfromalcoholpoisoningandmotorvehicleaccidents.Paralleltotheseconcernstherehavebeenrecentsuggestionsforamajorreviewofthelegislationandregulationofalcohol.Themostambitiousattemptinthisareahasbeentherecent2009LawCommissionreportwhichprovidesacomprehensiveoverviewoftheregulationofalcoholwithinNewZealandandsetsforthaseriesofproposalsforthepossibleintroductionofnewlegislationcentredarounddemandreduction(e.g.increasingthepriceofalcohol);supplycontrol(e.g.raisingthedrinkingage)andproblemlimitationstrategies(e.g.reducingthelegalbloodalcohollimit)[53,54,139].
TheworkoftheLawCommissionhasbeensupplementedbyapublicadvocacycampaignby Alcohol Action [140] who has proposed what has come to be known as the 5+solution.Thissolutionis: (1)raisealcoholprices;(2)raisethepurchaseage;(3)reduce
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alcohol availability; (4) reduce marketing and advertising; (5) increase drink-drivingcountermeasures+(increasedtreatmentopportunitiesforheavydrinkers).
It is also important that greater investment is made into research and evaluation todocumenttheconsequencesofpolicychange.Thereductionofthedrinkingageto18in1999providesaclearexampleoftheneedforevaluationtobebuiltintopolicychange.Whilstthereductionofthedrinkingageto18wasamajorsocialpolicychange,noclearplanwasdeveloped toevaluate the consequencesof this change.Whilst anumberofevaluations have been conducted [e.g. 141-143] these have been limited because ofproblemsofdataqualityanddataavailability. Inturn,thelackofsystematicevaluationof the evidence has complicated the process of policy debate and reform. It may besuggestedthathadaclearplanbeendevelopedforevaluatingtheconsequencesof1999reformswith this informationbeing provided to Parliament,manyof thedebates andconcerns thathavebeenexpressedabout furtherchanges to the lawcouldhavebeenaddressedbyevidenceratherthanopinion.Forthesereasonsitisimportantthatwhenmajorpolicy change is contemplatedevaluation isbuilt into thepolicy changeprocessso thatclearconclusionsmaybedrawnabout theeffectivenessorotherwiseofpolicychange. If applied consistently this strategy could result in an evolutionary process inwhichgoodpoliciesarestrengthenedand reinforcedby researchevidencewhilstpoorpoliciesareidentifiedanddiscarded.
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Appendix 1: Summary of evidence on effective treatmentsThe review in the main chapter provides an overview of the evidence regarding theeffectiveinterventionstoaddressalcoholrelatedproblemsinyoungpeople.Thisevidenceisbasedonalargebodyofresearchconductedaroundtheworld.ThemajorfindingsfromthisbodyofresearchhavebeensummarisedbyBaboretal. intheaward-winningtextAlcohol – No Ordinary Commodity[91].
Appendix 2: Cost benefits of effective treatments for alcohol misuseAlcohol – No Ordinary Commodity [91] summarisesevidenceon thecosteffectivenessof various interventions using an analysis paper for theWorld HealthOrganization byAnderson[144]whoconductedadetailedcost-benefitanalysisofalcoholpoliciesinthreeregions:theAmericas(e.g.BrazilandMexico),EasternEurope(e.g.RussiaandUkraine),and theWestern Pacific (e.g. China andVietnam).On the basis of this analysis itwasconcluded:
• Two strategies (school-based education and mass-media awareness campaigns)werefoundnottobecost-effectivebecausetheydonotaffectalcoholconsumptionor health outcomes.
• Population-levelalcoholpolicies(e.g.pricingandavailabilitypolicies)aremorecost-effective than individual-level policies, such as brief interventions for hazardousalcohol use.
• Tax increases represent a highly cost-effective response in regions with a highprevalenceofheavydrinking,suchasLatinAmericaandEasternEurope.
• The impactof reducingaccess to retailoutlets forspecifiedperiodsof theweekandimplementingacomprehensiveadvertisingbanhavethepotentialtobecost-effectivecountermeasures,butonlyiftheyarefullyenforced.